when it comes to providing universal coverage and financial protection from the costs of illness and injury, non-Americans have almost nothing of value to learn from us. Even after the ACA’s health insurance expansions are fully implemented by 2016-2017, the US will still have the most inefficient, expensive, wasteful, and unfair coverage system of any advanced nation on the planet.

The number of Medicaid-enrolled patients with newly identified diabetes increased by 23% (14,625 vs. 18,020 patients) in the 26 states (and District of Columbia) that expanded Medicaid compared with an increase of 0.4% (11,612 vs. 11,653 patients) in the 24 states that did not expand Medicaid during this period. Similar differences were observed in younger and older adults and for both men and women.

CONCLUSIONS This study suggests that in the states that expanded Medicaid under the ACA, an increased number of Medicaid patients with diabetes are being diagnosed and treated earlier. This could be anticipated to lead to better long-term outcomes.

A patchwork of experiments across the country are trying to better manage these cases. The Center for Health Care Strategies, a policy center in New Jersey, has documented such efforts in 26 states. Some are run by private insurers and health care providers, while others are part of broader state overhaul efforts. The federal government is supporting some, too, through its $10 billion Innovation Center, set up under the Affordable Care Act.

A physician friend of mine posted a copy of her Medicaid reimbursement on Facebook. Take a look at the charges compared to the actual reimbursement. She is paid between $6.82 and $17.54 for an hour of her time (i.e., on average, she makes less than minimum wage when treating a patient on Medicaid).

In reality, treating Medicaid patients is charity work. The fact that any physicians accept Medicaid is a testament to their generosity of spirit and missionary mindset. Expanding their pro bono workloads is nothing to cheer about. The Affordable Care Act’s “signature accomplishment” is tragically flawed – because offering health insurance to people that physicians cannot afford to accept is not better than being uninsured.

The ED directors we spoke with in hospitals in Medicaid expansion states reported reductions in the share of ED patients without insurance and corresponding increases in the share with Medicaid. However, uninsured rates remained high in all the safety-net EDs.

The ED directors’ expectations regarding trends in ED visit volume over the next few years varied. Some anticipated increased visits, citing pressures on primary care access, remaining large uninsured populations, or expanded ED capacity. Others anticipated flat or declining ED visits due to expanded coverage and access and the impact of new models of health care delivery and payment.

The ED directors we interviewed were not certain what the net impact of expanded coverage, large remaining uninsured populations, DSH cuts, delivery system reforms, and other ongoing changes will be on ED finances.

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The Affordable Care Act has ushered in an era of complex new health insurance products featuring legions of out-of-pocket coinsurance fees, high deductibles and narrow provider networks. Though commercial insurers had already begun to shift toward such policies, the health care law gave them added legitimacy and has vastly accelerated the trend, experts say.

The theory behind the policies is that patients should bear more financial risk so they will be more conscious and cautious about health care spending. But some experts say the new policies have also left many Americans scrambling to track expenses from a multitude of sources — such as separate deductibles for network and non-network care, or payments for drugs on an insurer’s ever-changing list of drugs that require high co-pays or are not covered at all.

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Paying Till It HurtsAPRIL 18, 2014

For some, like Ms. Pineman, narrow networks can necessitate footing bills privately. For others, the constant changes in policy guidelines — annual shifts in what’s covered and what’s not, monthly shifts in which doctors are in and out of network — can produce surprise bills for services they assumed would be covered. For still others, the new fees are so confusing and unsupportable that they just avoid seeing doctors.